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Swine Flu Update

On 5 May 2009, I arrived at my south London general practice to discover that I was at the "epicentre" of the H1N1 outbreak in the UK. Two local schools had been closed because of diagnosed cases of swine flu among their pupils. However, by the time the new cases of swine flu had come to light, many people would have been exposed, some of them developing subclinical infection or minor symptoms and not seeking medical advice. Closing the schools may therefore not limit the spread of the H1N1 virus because exposed and potentially infected people are still carrying out normal social activities. Subsequent research from some of my colleagues at Imperial College suggests that school closure may be beneficial in flu outbreaks. I am more cautious about applying this evidence from areas very far from central London.

My local health protection unit was unable to screen people with symptoms who had been in contact with swine flu cases. General practitioners were instead asked to do this at patients’ homes. The more logical solution would have been for the health protection unit to have established centralised testing and treatment centres to ensure that suspected cases were investigated promptly by trained staff and prophylactic treatment given if indicated. This is something that should be looked at because trying to combine routine clinical services whilst at the same time dealing with contact tracing is very difficult and disruptive.

The experience in my 10,000 patient practice in a place where many people would have been exposed to swine flu cases showed no evidence of widespread dissemination of the H1N1 virus in the early phase of the outbreak. The number of people presenting with symptoms of influenza or other viral illnesses remained low and at the expected rate in early summer. There was then a marked increase in June 2009 but consultations for viral infections then fell substantially in July and August. The cases that have presented to the practice have all generally been mild and recovered quickly. If this pattern is repeated elsewhere, the eventual number of deaths and complications from swine flu may be substantially less than that predicted by some of the more pessimistic commentators.

I am concerned about the widespread use of Tamiflu (Oseltamivir). By using antiviral drugs so liberally — for what is currently a mild form of flu — we risk generating resistance so that when a more virulent form of flu presents the drugs may no longer be effective. Moreover, in areas where testing is still going on, as few as 10-20% of suspected cases have confirmed H1N1 infection, meaning that many patients who receive Tamiflu don't actually have swine flu. The current policy may therefore have very limited benefits, even without taking into account the enormous resource implications, the important work left undone as general practitioners and others focus their efforts on swine flu, and the loss of staff goodwill. I question the need to continue the use of antiviral drugs for people who are not in at risk groups.

Report from the UK "epicentre"
http://www.bmj.com/cgi/content/extract/338/may27_3/b2094

Policy on antiviral drugs needs to be revised
http://www.bmj.com/cgi/content/extract/339/jul08_3/b2728

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